In situations where first-hand, contemporaneous consent cannot be obtained from potential research participants—such as from those who lack competence—consent may be sought from a proxy, such as a family member. Such proxy consent must be shown to have a sound moral justification if it is to be an acceptable alternative to first-hand consent. Two standards traditionally proposed for this purpose are those of substituted judgment and best interests. We describe and discuss the limitations of these two approaches, with particular reference to ways in which the context of research differs from that of clinical practice, where proxy consent has been more widely utilized. Other approaches that expand upon or depart from these traditional justifications are then discussed, namely the authentic life, endorsed life, and substituted interests models, as well as one that grounds proxy consent in a putative obligation to participate in research. Whilst these models obviate some of the limitations of the substituted judgment and best interests approaches, they have shortcomings of their own, and do not take full account of all of the relevant values and motivations that obtain in the context of clinical research. We propose an alternative and, in our view, more fruitful approach to justifying proxy consent to research participation—based on W D Ross’s moral intuitionism—that does not rest upon a single moral principle but can accommodate a range of both deontological and consequentialist prima facie values.

Background: Physically Disabled women face multiple barriers to cervical screening, contributing to lower uptake and increased health inequalities. Human papillomavirus self-sampling has been shown to increase screening participation in under-screened populations, but little is known about its acceptability for Disabled women. Methods: A cross-sectional online survey was conducted with 1493 UK-based participants who identified as having a physical disability, impairment, condition, or difference that makes cervical screening difficult or impossible. Participants completed questions on the acceptability of human papillomavirus self-sampling, attitudes and beliefs relating to self-sampling, and future screening preferences. Descriptive statistics and multinomial logistic regression were used to analyse responses. Results: Most participants reported that they would be able to carry out self-sampling themselves (63.3%) and would be willing for a healthcare professional to use a self-sampling kit on their behalf (59.1%). Many (70.5%) had concerns about not performing the test correctly. Around half (53.0%) would prefer self-sampling at home if offered a screening choice. Women who had never attended screening, or who had delayed/missed appointments, were significantly more likely to prefer self-sampling (odds ratios 13.11 and 5.25, respectively) than women who had always attended. Approximately a fifth of participants (18.7%) would prefer a non-speculum clinician-taken test. Conclusion: Human papillomavirus self-sampling was acceptable to many physically Disabled women and preferred over conventional screening, particularly among those who had delayed/missed screening or never attended. Implementation should include tailored accessible instructions to support human papillomavirus self-sampling, disability-informed clinical support, and consideration of non-speculum clinician-taken samples to ensure equitable access and reduce inequalities in cervical screening.

Background Physically Disabled women are less likely to access cervical screening than non-disabled women, yet little research has been conducted to understand the problems that Disabled women face or potential solutions. Methods A cross-sectional online survey was conducted with 1493 UK-based participants who identified as having a physical disability, impairment, condition, or difference that makes cervical screening difficult or impossible. Participants were presented with statements about cervical screening problems and potential solutions and asked to indicate agreement using a 5-point scale. They also provided open-ended comments. Data were analysed using descriptive statistics, multinomial logistic regression and thematic analysis. Results More than half of participants reported delaying/missing (46.8%) or never attending (8.8%) screening, with most of those (71.0% and 81.4% respectively) indicating that the main reason was disability-related factors. The highest levels of agreement for problems were for concerns about pain, embarrassment, and fear of what the test might find and for potential solutions were for having a doctor or nurse who is willing to try different solutions, discusses specific needs, and understands physical disability. Never-attendance (OR = 0.022, 95% CI 0.014, 0.035) and delaying or missing appointments, (OR = 0.057, 95% CI 0.043, 0.076) negatively predicted future screening attendance. Six themes were identified from open-ended comments, supporting and extending the quantitative findings. Conclusion Disabled women face the same problems related to cervical screening as non-disabled women and additionally face disability-specific problems. Cervical sample taker training should incorporate ways to support physically Disabled women to have equitable access to screening. ### Competing Interest Statement Susan Sherman is a Trustee for the British Society for Colposcopy and Cervical Pathology. The authors declare no other potential competing interests with respect to the research, authorship, and/or publication of this article. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was granted ethical approval from Keele University Research Ethics Committee (REF: REC Project Reference 0787) and the University of Sheffield School of Psychology research ethics committee (REF: 064385). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The quantitative data are available at: https://osf.io/ufx8r/files/tm2us The qualitative data will be available from the OSF project page following peer review: https://osf.io/ufx8r/overview NIHR, NIHR204322 National Institute for Health and Care Research (NIHR) Applied Research Collaboration West Midlands, NIHR200165

It is not known whether people living with Parkinson’s (PlwP) were actually achieving the recommended level of physical activity before and during the COVID-19 lockdown in the UK. This study aimed to find out: 1) whether PlwP are aware of the UK Chief Medical Officer’s physical activity recommendations for older adults, and if PlwP were following these recommendations before and subsequently during the COVID-19 pandemic; 2) what modes of exercise were used by PlwP to keep exercising during the COVID-19 restrictions; and 3) the preferences of PlwP in terms of self-managed exercise programmes to inform the design of future intervention studies. An online questionnaire was developed by the research team, focusing on physical activity level and mode before the quarantine, during the pandemic, and on their preference in terms of future self-management mode of exercise. Adults who had been diagnosed with Parkinson’s and were receiving emails from Parkinson’s UK Research Support Network were eligible to participate. Any person unable to read English was excluded. There were 416 responders to the questionnaire. There was a decrease in physical activity in PlwP during the pandemic. People mostly missed the social contact in exercise groups. Online virtual exercise classes, stationary cycling, treadmill running, and DVD exercises were the preferred modes of remote/indoor exercise methods. These findings indicate the importance of designing remote or minimally supervised exercise trial interventions, taking into consideration people’s preferences regarding mode of exercise and social contact.

Background Preservation of residual kidney function (RKF) in dialysis patients has been associated with improved survival. RKF in the BISTRO trial was relatively well preserved, and in this study, we describe its association with survival during the trial and extended follow-up. Methods RKF, measured as the average urea and creatinine clearance (GFR) or 24-hour urine volume, was assessed at baseline; 1, 2, and 3 months; and every three months for up to 2 years in incident hemodialysis patients. Time to event survival data or competing events (transplantation, modality change) was obtained for 50 months after enrollment via data linkage with the UK Renal Registry. Cox proportional hazards regression survival models, including those incorporating change in GFR from baseline as a time-varying variable and joint regression models for longitudinal and survival data (longitudinal models for GFR or urine volume), were used to explore the relationship of RKF preservation with survival. Analyses were adjusted for age, sex, comorbidity, and ethnicity. Results A total of 2919 measures of RKF were made in 387 patients from 32 UK dialysis units. Higher age and comorbidity score were associated with increased mortality in all models. Baseline GFR reduced the risk of death (hazard ratio [HR], 0.918; 95% confidence interval [CI], 0.844 to 0.999) per ml/min per 1.73 m(2). A greater fall in GFR and urine volume from baseline was associated with a nonsignificant increased risk of death, as visualized on spline plots. In the joint survival models, higher GFR (adjusted HR, 0.88; 95% CI, 0.80 to 0.97) or urine volume (adjusted HR, 0.75, 95% CI, 0.57 to 0.95/L) at any time point was associated with better survival. Conclusions Lower RKF during the first 2 years of hemodialysis is associated with an increased death risk for up to 50 months after dialysis initiation. This adds to a growing body of evidence that interventions to preserve RKF should be developed and tested in clinical trials.

BACKGROUND:Currently, there is a paucity of long-term health data for retired athletes. This study describes the prevalence of common morbidities and multimorbidity among retired Great Britain's (GB) Olympic athletes, compared to a general population comparator group. METHODS:A cross-sectional study of retired athletes was undertaken. The English Longitudinal Study of Ageing (ELSA) served as the reference population. Age- and sex-standardized morbidity ratios (SMRs) and odd ratios (ORs) determined where morbidity and multimorbidity prevalence amongst retired athletes exceeded or were inferior to those of the reference population. RESULTS:Retired athletes (n = 493) were less likely (SMR < 1) than controls (n = 8024) to report diabetes (0.43, 99% CI 0.22, 0.74), stroke (0.39, 99% CI 0.12, 0.90), obesity (0.35, 99% CI 0.23, 0.50), asthma (0.29, 99% CI 0.12, 0.59), lung disease (0.29, 99% CI 0.06, 0.81), angina (0.18, 99% CI 0.05, 0.46), and eye disorders (0.06, 99% CI 0.01, 0.18). In addition, abnormal heart rhythm (0.45, 99% CI 0.40, 0.54) and osteoporosis (0.46, 99% CI 0.42, 0.51) were lower in female athletes. Retired athletes were more likely (SMR > 1) than controls to report melanoma or other skin cancer (5.64, 99% CI 2.80, 10.06) and osteoarthritis (1.44, 99% CI 1.18, 1.75). There were no differences detected in cancers of the breast, prostate, colon, bowel or bladder. Multimorbidity was less prevalent among retired athletes (OR 0.50, 99% CI 0.38, 0.67). CONCLUSIONS:Retired athletes had superior cardiovascular health and a lower risk of multimorbidity, but were more at risk of melanoma or other skin cancer and osteoarthritis.

Objective Fibromyalgia is a chronic condition that has major impact on people’s lives. This study examines individuals’ illness trajectories, with a particular focus on daily life experiences and self-managing. Methods Narrative interviews were conducted, asking participants to story their daily life experiences from illness onset to the present, and to reflect on the future. Embedded in their storying were experiences of recently being diagnosed, navigating daily life in the face of illness, and participating in a self-management intervention. The data underwent a narrative analysis. Results In keeping with the idiographic focus of narrative research, two individuals’ stories were chosen to portray an individualized process of self-managing illness in daily life. The storylines ‘Resuming prior self and life’ and ‘Taking life and self in new direction’ illuminate how individuals with differing illness trajectories and life situations autonomously apply resources available to them in their lives. They make sense of illness by bringing together their own lifeworld experiences of stress and factual knowledge and, through a process of individual agency, discover and try out what is right to do in their own life in the face of chronic illness. Conclusions These two storylines illustrate that a self-managing process is an individual process nested in the person’s social context. Self-management encompasses an individualized process of agency in remaking daily life and reconstructing a sense of self.

AIM:When developing public health measures in a pandemic, it is important to examine attitudes and beliefs relating to vaccination uptake. We report the discrimination of a single-item vaccination intention scale and derive cutpoints in terms of sensitivity (true positives) and specificity (true negatives) in relation to subsequent vaccination status. SUBJECT AND METHODS:In a sample of UK adults (n=1119) recruited through an online survey platform, vaccination intention was measured on a 0-10 numerical rating scale (0=very unlikely, 10=very likely) at the beginning of the UK COVID-19 vaccination rollout (January 2021), and self-reported vaccination status was gathered after vaccination had been offered to all adults (October 2021). Discrimination of the scale was measured by the area under the receiver operating characteristic (ROC) curve. RESULTS:The responders reporting being vaccinated or unvaccinated were 1034 (92.4%) and 85 (7.6%), respectively. The area under the ROC curve was.956 (95% CI.943,.967), indicating a high degree of discrimination. The combined value of sensitivity and specificity was greatest at a cutpoint of 8 on the scale (sensitivity =.821, specificity =.988). If, however, the individual values of sensitivity and specificity are required to be simultaneously optimized, this occurs at point 6 (sensitivity =.886, specificity =.871). CONCLUSION:We recommend a 0-10 intention scale as a validated, practical measure of vaccination intention in public health practice, with a cutpoint of 8 on the scale as optimal, unless sensitivity and specificity are to be simultaneously optimized, when 6 is the optimal cutpoint.

Background:The BioImpedance Spectroscopy to maintain Renal Output randomised controlled trial investigated the effect of bioimpedance spectroscopy added to a standardised fluid management protocol on the risk of anuria and preservation of residual kidney function (primary trial outcomes) in incident haemodialysis patients. Despite the economic burden of kidney disease, the cost-effectiveness of using bioimpedance measurements to guide fluid management in haemodialysis is not known. Objectives:To assess the cost-effectiveness of bioimpedance-guided fluid management against current fluid management without bioimpedance. Design:Within-trial economic evaluation (cost-utility analysis) carried out alongside the open-label, multicentre BioImpedance Spectroscopy to maintain Renal Output randomised controlled trial. Setting:Thirty-four United Kingdom outpatient haemodialysis centres, both main and satellite units, and their associated inpatient hospitals. Participants:Four hundred and thirty-nine adult haemodialysis patients with > 500 ml urine/day or residual glomerular filtration rate > 3 ml/minute/1.73 m2. Intervention:The study intervention was the incorporation of bioimpedance technology-derived information about body composition into the clinical assessment of fluid status in patients with residual kidney function undergoing haemodialysis. Bioimpedance measurements were used in conjunction with usual clinical judgement to set a target weight that would avoid excessive fluid depletion at the end of a dialysis session. Main outcome measures:The primary outcome measure of the BioImpedance Spectroscopy to maintain Renal Output economic evaluation was incremental cost per additional quality-adjusted life-year gained over 24 months following randomisation. In the main (base-case) analysis, this was calculated from the perspective of the National Health Service and Personal Social Services. Sensitivity analyses explored the impact of different scenarios, sources of resource use data and value sets. Results:The bioimpedance-guided fluid management group was associated with £382 lower average cost per patient (95% CI -£3319 to £2556) and 0.043 more quality-adjusted life-years (95% CI -0.019 to 0.105) compared with the current fluid management group, with neither values being statistically significant. The probability of bioimpedance-guided fluid management being cost-effective was 76% and 83% at commonly cited willingness-to-pay threshold of £20,000 and £30,000 per quality-adjusted life-year gained, respectively. The results remained robust to a series of sensitivity analyses. Limitations:The missing data level was high for some resource use categories collected through case report forms, due to COVID-19 disruptions and a significant dropout rate in the informing BioImpedance Spectroscopy to maintain Renal Output trial. Conclusions:Compared with current fluid management, bioimpedance-guided fluid management produced a marginal reduction in costs and a small improvement in quality-adjusted life-years. Results from both the base-case and sensitivity analyses suggested that use of bioimpedance is likely to be cost-effective. Future work:Future work exploring the association between primary outcomes and longer-term survival would be useful. Should an important link be established, and relevant evidence becomes available, it would be informative to determine whether and how this might affect longer-term costs and benefits associated with bioimpedance-guided fluid management. Funding details:This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number HTA 14/216/01 (NIHR136142).

Abstract Introduction Fluid assessment and management is a key aspect of good dialysis care and is affected by patient-level characteristics and potentially centre-level practices. In this secondary analysis of the BISTRO trial we wished to establish whether centre-level practices with the potential to affect fluid status were stable over the course of the trial and explore if they had any residual associations with participant’s fluid status. Methods Two surveys (S) of fluid management practices were conducted in 32 participating centres during the trial, (S1: 2017–18 and S2: 2021–22). Domains interrogated included: dialysate sodium concentration, (D-[Na+]), fluid and salt intake, residual kidney function, use of diuretics, incremental start, approaches to fluid assessment, management and dialysate temperature, (D-oC). Associations of these practices with the closeness of the participant’s post-dialysis target weight to their normally hydrated weight, pre- and post-dialysis systolic (SBP) and diastolic blood pressure, (DBP), were analysed using intra-class correlations and multilevel modelling with adjustment for visit, age, sex and comorbidity burden. Results Variations in centre practices were reported but did not change during the trial, apart from some relaxation in salt and fluid restriction in S2. For our measures of fluid status, measured 2501 times in 439 non-anuric incident haemodialysis patients, centre-level intraclass correlations were extremely low, whereas patient-level correlations ranged between 0.12 and 0.47, strongest for pre- and post-dialysis-SBP, less so for post-dialysis-DBP. Multi-level analysis found no associations between D-[Na+], or assessment methods of fluid status. In S2, one centre, routinely using a D-Co of 35°C had more divergence between the target and normally hydrated weight, but this was not observed in S1, and no other associations were found. Conclusions Centre-level fluid management practices were stable over the course of the BISTRO trial, and in contrast to patient-level factors, no centre-level associations were detected with fluid status or blood pressure. This may be because the trial imposed a standardised approach to fluid assessment in all trial participants who at least initially had residual kidney function, potentially over-riding the effects of other centre practices. Survey responses revealed substantial scope for developing and evaluating standardised protocols to optimise fluid management.

Key Points Residual kidney function during the first 2 years of hemodialysis treatment is associated with a long-term (>4 years) survival advantage.Incorporating bioimpedance measurements to inform the setting of the postdialysis target weight does not affect patient survival. Background Preservation of residual kidney function (RKF) in dialysis patients has been associated with improved survival. RKF in the BISTRO trial was relatively well preserved, and in this study, we describe its association with survival during the trial and extended follow-up. Methods RKF, measured as the average urea and creatinine clearance (GFR) or 24-hour urine volume, was assessed at baseline; 1, 2, and 3 months; and every three months for up to 2 years in incident hemodialysis patients. Time to event survival data or competing events (transplantation, modality change) was obtained for 50 months after enrollment via data linkage with the UK Renal Registry. Cox proportional hazards regression survival models, including those incorporating change in GFR from baseline as a time-varying variable and joint regression models for longitudinal and survival data (longitudinal models for GFR or urine volume), were used to explore the relationship of RKF preservation with survival. Analyses were adjusted for age, sex, comorbidity, and ethnicity. Results A total of 2919 measures of RKF were made in 387 patients from 32 UK dialysis units. Higher age and comorbidity score were associated with increased mortality in all models. Baseline GFR reduced the risk of death (hazard ratio [HR], 0.918; 95% confidence interval [CI], 0.844 to 0.999) per ml/min per 1.73 m2. A greater fall in GFR and urine volume from baseline was associated with a nonsignificant increased risk of death, as visualized on spline plots. In the joint survival models, higher GFR (adjusted HR, 0.88; 95% CI, 0.80 to 0.97) or urine volume (adjusted HR, 0.75, 95% CI, 0.57 to 0.95/L) at any time point was associated with better survival. Conclusions Lower RKF during the first 2 years of hemodialysis is associated with an increased death risk for up to 50 months after dialysis initiation. This adds to a growing body of evidence that interventions to preserve RKF should be developed and tested in clinical trials.

Objective: To investigate symptom reporting following the first and second COVID-19 vaccine doses, attribution of symptoms to the vaccine, and factors associated with symptom reporting.Methods: Prospective cohort study (T1: 13-15 January 2021, T2: 4-15 October 2021). Participants were aged 18 years or older, living in the UK. Personal, clinical, and psychological factors were investigated at T1. Symptoms were reported at T2. We used logistic regression analyses to investigate associations.Results: After the first COVID-19 vaccine dose, 74.1% (95% CI 71.4% to 76.7%, n = 762/1028) of participants reported at least one injection-site symptom, while 65.0% (95% CI 62.0% to 67.9%, n = 669/1029) reported at least one other (non-injection-site) symptom. Symptom reporting was associated with being a woman and younger. After the second dose, 52.9% (95% CI 49.8% to 56.0%, n = 532/1005) of participants reported at least one injection-site symptom and 43.7% (95% CI 40.7% to 46.8%, n = 440/1006) reported at least one other (non -injection-site) symptom. Symptom reporting was associated with having reported symptoms after the first dose, having an illness that put one at higher risk of COVID-19 (non-injection-site symptoms only), and not believing that one had enough information about COVID-19 to make an informed decision about vaccination (injection-site symptoms only).Conclusions: Women and younger people were more likely to report symptoms from vaccination. People who had reported symptoms from previous doses were also more likely to report symptoms subsequently, although symptom reporting following the second vaccine was lower than following the first vaccine. Few psychological factors were associated with symptom reporting.

Objectives: To explore acceptability of and preferences for the introduction of varicella vaccination to the UK childhood immunisation schedule.Design: We conducted an online cross-sectional survey exploring parental attitudes towards vaccines in general, and varicella vaccine specifically, and their preferences for how the vaccine should be administered.Participants: 596 parents (76.3% female, 23.3% male, 0.4% other; mean age 33.4 years) whose youngest child was aged 0-5 years. Main outcome measures: Willingness to accept the vaccine for their child and preferences for how the vaccine should be administered (in combination with the MMR vaccine [MMRV], on the same day as the MMR vaccine but as a separate injection [MMR + V], on a separate additional visit).Results: 74.0% of parents (95% CI 70.2% to 77.5%) were extremely/somewhat likely to accept a varicella vaccine for their child if one became available, 18.3% (95% CI 15.3% to 21.8%) were extremely/somewhat unlikely to accept it and 7.7% (95% CI 5.7% to 10.2%) were neither likely nor unlikely. Reasons provided by parents likely to accept the vaccine included protection from complications of chickenpox, trust in the vaccine/healthcare professionals, and wanting their child to avoid their personal experience of chickenpox. Reasons provided by parents who were unlikely included chickenpox not being a serious illness, concern about side effects, and believing it is preferable to catch chickenpox as a child rather than as an adult. A combined MMRV vaccination or additional visit to the surgery were preferred over an additional injection at the same visit.Conclusions: Most parents would accept a varicella vaccination. These findings highlight parents' preferences for varicella vaccine administration, information needed to inform vaccine policy and practice and development of a communication strategy.(c) 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

Background: We investigated factors associated with COVID-19 vaccine uptake, future vaccination intentions, and changes in beliefs and attitudes over time.Methods: Prospective cohort study. 1500 participants completed an online survey in January 2021 (T1, start of vaccine rollout in the UK), of whom 1148 (response rate 76.5 %) completed another survey in October 2021 (T2, all UK adults offered two vaccine doses). Binary logistic regression analysis was used to investigate factors associated with subsequent vaccine uptake. Content analysis was used to investigate the main reasons behind future vaccine intentions (T2). Changes in beliefs and attitudes were investigated using analysis of variance.Findings: At T2, 90.0 % (95 % CI 88.2-91.7 %) of participants had received two doses of a COVID-19 vaccine, 2.2 % (95 % CI 1.3-3.0 %) had received one dose, and 7.4 % (95 % CI 5.9-8.9 %) had not been vaccinated. Uptake was associated with higher intention to be vaccinated at T1, greater perceived vaccination social norms, necessity of vaccination, and perceived safety of the vaccine. People who had initiated vaccination reported being likely to complete it, while those who had not yet received a vaccine reported being unlikely to be vaccinated in the future. At T2, participants perceived greater susceptibility to, but lower severity of, COVID-19 (p < 0.001) than at T1. Perceived safety and adequacy of vaccine information were higher (p < 0.001).Interpretation: Targeting modifiable beliefs about the safety and effectiveness of vaccination may increase uptake. (c) 2023 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

INTRODUCTION:Studies show that the COVID-19 pandemic disproportionately affected people with diabetes and those from disadvantaged backgrounds. During the first 6 months of the UK lockdown, > 6.6 M glycated haemoglobin (HbA1c) tests were missed. We now report variability in the recovery of HbA1c testing, and its association with diabetes control and demographic characteristics. METHODS:In a service evaluation, we examined HbA1c testing across ten UK sites (representing 9.9% of England's population) from January 2019 to December 2021. We compared monthly requests from April 2020 to those in the equivalent 2019 months. We examined effects of (i) HbA1c level, (ii) between-practice variability, and (iii) practice demographics. RESULTS:In April 2020, monthly requests dropped to 7.9-18.1% of 2019 volumes. By July 2020, testing had recovered to 61.7-86.9% of 2019 levels. During April-June 2020, we observed a 5.1-fold variation in the reduction of HbA1c testing between general practices (12.4-63.8% of 2019 levels). There was evidence of limited prioritization of testing for patients with HbA1c > 86 mmol/mol during April-June 2020 (4.6% of total tests vs. 2.6% during 2019). Testing in areas with the highest social disadvantage was lower during the first lockdown (April-June 2020; trend test p < 0.001) and two subsequent periods (July-September and October-December 2020; both p < 0.001). By February 2021, testing in the highest deprivation group had a cumulative fall in testing of 34.9% of 2019 levels versus 24.6% in those in the lowest group. CONCLUSION:Our findings highlight that the pandemic response had a major impact on diabetes monitoring and screening. Despite limited test prioritization in the > 86 mmol/mol group, this failed to acknowledge that those in the 59-86 mmol/mol group require consistent monitoring to achieve the best outcomes. Our findings provide additional evidence that those from poorer backgrounds were disproportionately disadvantaged. Healthcare services should redress this health inequality.

Objectives: To determine the influence of severity and direction (craniocaudal length vs cross-sectional area) of intramuscular tendon tears in the lower limb on return-to-play times, compared to muscle injuries without in-tramuscular tendon involvement.Design: Systematic review with meta-analysis.Methods: AMED, CINAHL, SPORTDiscus, ScienceDirect, PubMed (MEDLINE) and Web-of-Science were searched from inception to 31st July 2023, retrieving 666 records, of which nine were deemed eligible. A random-effects meta-analysis was performed on time to return-to-play for British Athletics Muscle Injury Classification 'b' vs'c'. Results: On the Quality in Prognosis Studies tool, one study had low risk of bias and eight had high risk. Using a best-evidence synthesis, no strong evidence emerged fora difference in time to return-to-play between injuries with or without intramuscular tendon involvement. Moderate evidence was found for an association between increased return-to-play time and the presence of "waviness" on magnetic resonance imaging and loss of tendon tension, but no association with longitudinal extent of tendon involvement. Pooled analysis revealed a medium effect-size difference between British Athletics Muscle Injury Classification 'b' and 'c' injuries, favouring classifi-cation 'b' (Hedges g = 0.67; 95% confidence interval 0.20 to 1.15; P = 0.002).Conclusions: It remains difficult to provide an accurate prognosis for muscle injuries involving the intramuscular tendon due to high risk of bias and moderate heterogeneity across studies. Moderate evidence favoured the prog-nosis for injuries at the musculotendinous junction (British Athletics Muscle Injury Classification 'b') over intratendinous injuries (British Athletics Muscle Injury Classification 'c').(c) 2023 The Author(s). Published by Elsevier Ltd on behalf of Sports Medicine Australia. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Although experiences of loss and the consequent grief are natural in human life, some individuals may have difficulty managing these events, to the point of developing significant impairment in their functioning in important life areas. Given this, the present research aimed to explore the psychometric properties of the Italian version of the Adult Attitude to Grief scale (AAG) to facilitate research on adult vulnerability to grief among Italian-speaking populations. A sample of 367 participants (Mage = 30.44, SD = 11.21; 78% females) participated in this research. A back-translation procedure was implemented to develop the Italian AAG. Then, participants completed the Italian AAG alongside a battery of other self-report psychometric scales in order to assess aspects of the construct validity of the AAG: the Forty-Item Defense Style Questionnaire, the Impact of Event Scale-Revised, and the Beck Depression Inventory-II. A bifactor structure was found to have the best fit to the data, supporting the possibility of using both the general factor (i.e., vulnerability) and three dimensions (i.e., overwhelmed, controlled, and resilient). Unlike the original version, the control dimension emerged as a "protective" factor in the Italian population, together with the resilient factor. Furthermore, results provided satisfactory indications of internal consistency and construct validity. In conclusion, the Italian AAG was shown to be a valid, reliable, quick, and easy-to-use scale that can be used both for research and clinical practice in the Italian context.